A nurse is preparing to suction secretions from a patient who has a new tracheostomy. Which of the following actions should the nurse plan to take?
Use a resuscitation bag with 80% oxygen prior to the procedure.
Select a suction catheter that is half the size of the lumen.
Place the end of the suction catheter in water-soluble lubricant.
Adjust the wall suction apparatus to a pressure of 170 mm Hg.
The Correct Answer is B
Choice A rationale: Using a resuscitation bag with 80% oxygen prior to the procedure is inappropriate. While pre-oxygenation is important before suctioning to prevent hypoxia, the oxygen concentration should be 100%, not 80%. Normal oxygen saturation levels are 95% to 100%. Pre-oxygenating with 100% oxygen ensures the patient maintains adequate oxygenation during the brief suctioning period. Using 80% oxygen does not fully optimize oxygen reserves for this purpose.
Choice B rationale: Selecting a suction catheter that is half the size of the tracheostomy lumen is appropriate. This size prevents excessive occlusion of the airway, ensuring adequate airflow during suctioning. The correct catheter size minimizes trauma to the tracheal mucosa and prevents hypoxia. The catheter should not exceed 50% of the tracheostomy diameter to maintain proper airway function, making this the correct action for safe and effective suctioning.
Choice C rationale
Placing the end of the suction catheter in water-soluble lubricant is not recommended. This could introduce bacteria into the airway and increase the risk of infection.
Choice D rationale
Adjusting the wall suction apparatus to a pressure of 170 mm Hg is not correct. The recommended suction pressure for adults is usually between 80 and 120 mm Hg. Suctioning at too high a pressure can cause trauma to the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C,A,D,B
Explanation
Choice A rationale
Injecting 5 units of air into the bottle of regular insulin is the second step in the procedure. This is done after injecting air into the NPH insulin bottle. The purpose of this step is to pressurize the vial, making it easier to withdraw the insulin.
Choice B rationale
Withdrawing the correct dose of NPH insulin from the bottle is the last step in the procedure. This is done after withdrawing the regular insulin to prevent contamination of the regular insulin with the NPH insulin.
Choice C rationale
Injecting 10 units of air into the bottle of NPH insulin is the first step in the procedure. This is done before injecting air into the regular insulin bottle. The purpose of this step is to pressurize the vial, making it easier to withdraw the insulin.
Choice D rationale
Withdrawing the correct dose of regular insulin from the bottle is the third step in the procedure. This is done after injecting air into the regular insulin bottle and before withdrawing the NPH insulin. The purpose of this step is to ensure that the correct dose of regular insulin is administered.
Correct Answer is B
Explanation
Choice A rationale
When descending stairs, the crutches and the injured leg should go down first, followed by the good leg31415.
Choice B rationale
Placing crutches 12 inches in front and to the side of each foot is a correct method for using crutches. This provides stability and balance while walking31415.
Choice C rationale
When sitting down, it’s recommended to hold both crutches in one hand on the same side as the injured leg. This allows the other hand to be free to reach for the chair31415.
Choice D rationale
The shoulder rests, or pads, should not be snug against the body. There should be a space of about 1-2 inches between the top of the crutch and the armpit31415.
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